July 31, 2009 - Praying in the Tube

Finishing out my vacation, I’ve been enjoying some quiet time up at our Adirondacks place, near Jay, New York. One of the good books I’ve been reading is Why Faith Matters, by Rabbi David J. Wolpe. David thoughtfully sent me a copy of his book, after reading my May 9, 2009 blog entry about him.

The book has a lot to recommend it. It’s a thoughtful, honest answer to recent critics from the scientific world, like Christopher Hitchens and Richard Dawkins, who have ridiculed faith and elevated scientific insights in its place. (It’s also a quick read, very accessible to people without extensive training in either theology or science.)

David is in the same place I am on that question, maintaining that religion and science need not be in conflict with one another. There’s no reason why a scientist cannot also be a religious believer, nor a believer someone who also accepts the insights of evolutionary biology or physics.

One part of the book that speaks personally to me is when David shares his personal experience as a cancer survivor. Like me, he has non-Hodgkin lymphoma, in an incurable form. Some years previously, he had surgery to remove a brain tumor. Here, he writes of his experience of prayer, as he’s undergone various medical tests:

“Throughout my various illnesses, I prayed. My prayer was not answered because I lived; my prayer was answered because I felt better able to cope with my sickness. Each time I go for my regular tests, the CT or PET scans or an MRI, each time I am moved into the metal tube that will give an image of sickness or health, I pray. I do not pray because I believe God will give me a clear scan. I pray because I am not alone, and from gratitude that having been near death I am still in life. I pray not for magic but for closeness, not for miracles but for love.

The novelist George Meredith wrote, ‘Who rises from his prayer a better man, his prayer is answered.’”

– Why Faith Matters (HarperOne, 2008), p. 25.

Some of the most heartfelt prayers any of us pray are those uttered “in the tube.” When we find ourselves in the tube, what do we pray for? Miracles?

I’ve wondered, on similar occasions, what the point is of praying for a negative test result (“negative” is, of course, a positive or good result in medical parlance). The machine, be it CT scanner or PET scanner or whatever, is simply taking a picture of whatever is there. I’m not praying for the result to come out skewed, of course – it’s in my best interest that the test be accurate, that my doctors fully understand whatever’s going on inside my body. When we offer prayers in the tube, are we praying that, if there’s a malignancy there, God will vaporize it then and there, in the few seconds before the picture is taken?

No, as David indicates, I think prayer is a good bit more complex than that. When we pray, we often do have specific results in mind, but more importantly, we’re seeking to be in communion with God, and perhaps also to feel a sense of solidarity with others who form the community of prayer. Indeed, we pray “not for magic but for closeness, not for miracles but for love.”

Of miracles, C.S. Lewis once wrote: “Miracles are a retelling in small letters of the very same story which is written across the whole world in letters too large for some of us to see.”

The point is, to catch that larger vision.

Prayer changes things. Prayer changes us.

July 22, 2009 - Dulanermin

Paging through an old copy of Cure magazine (a publication for cancer survivors), I notice a headline in a full-page ad: “Have you been diagnosed with Follicular Non-Hodgkin’s Lymphoma (NHL) following previous rituximab therapy?”

“That’s me,” says I to myself.

Reading on, I discover it’s an ad for a clinical trial being conducted by Genentech – the drug company that brought us rituximab (Rituxan). They’re also the people who flew Claire and me to Las Vegas a few years ago, to give a little motivational talk to their sales force.

Down at the bottom is a serial number I can use at the clinicaltrials.gov website, to find out more about this study.

I visit that site, key in the number, and come up with a page describing a study of a new investigational drug called Apo2L/TRAIL – trade name, Dulanermin.

It’s a Phase II clinical trial – which means it’s still in the early stages of investigation. As of now, the trial is also fully subscribed: which may be just as well, since I’m not sure I’d want to risk the side effects of a Phase II trial when I’m still in a watch-and-wait mode and feeling good.

It’s interesting to read about this new drug, all the same, because it could be in my future.

Here’s the scoop, from an Amgen press release of a couple months ago (the Amgen pharmaceutical company is conducting this research in partnership with Genentech). Dulanermin is one of a family of “highly selective therapies to induce cancer cell death.” Well, who can argue with that?

“In cancer,” the article continues, “the dysregulation of apoptosis is critical in the development and survival of tumors.” I know, from previous reading, that apoptosis is cell death – the normal tendency of cells to die according to a genetically-preset timetable, only to be replaced by new cells. In cancer cells, the apoptosis switch is turned off, allowing them to continue to grow and wreak havoc in the body. “The dysregulation of apoptosis” is inscrutable medical jargon for “throwing a wrench into the genetic machinery that would otherwise cause cells to die when they reach the end of their natural lifespan.”

Dulanermin – if it fulfills the hopes of the pharmaceutical researchers – would yank that monkey-wrench back out of the machinery, so cells would continue to die according to their normal timetable and would never morph into cancer cells.

The article defines dulanermin as “a recombinant human protein that targets death receptors 4 and 5.” Sounds like something out of Star Wars: “Luke, your mission is to fly your X-fighter along the surface of the Death Star and take out death receptors 4 and 5. May the Force be with you.”

Go for it, Luke.

Is this the next Rituxan? Impossible to say. Clinical trials like this are being conducted all the time, mostly below the radar of non-medical types like me. Every once in a while, a full-page ad jumps out at us, a reminder that this valuable work is going on.

Kudos to the researchers for keeping up with this sort of thing.

Who knows? If this one ever makes it to a Phase III trial, maybe they can sign me up.

July 20, 2009 - Where Not to Get Sick

If you haven’t yet read Atul Gawande’s article in the June 1, 2009 New Yorker about the high cost of health care in McAllen, Texas, you should. It’s a must-read for anyone who’s following the health care funding debate.

Why McAllen? Why should that dusty burg at the southern tip of Texas have the highest per capita health care costs in America? Gawande’s article is a detective story, chronicling his efforts to answer that question.

The answer he comes up with is that McAllen’s doctors are responsible for many of these elevated costs. They order up a whole lot of costly, high-tech medical tests, more than most other doctors around the country:

“The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.”

Remarkably, the highly-tested patients of McAllen are no healthier than patients elsewhere. Compared to some cities with lower medical costs, they actually do worse.

It’s not that McAllen’s doctors are less competent than doctors elsewhere, or that they’re morally challenged. Gawande’s explanation is that the entire medical system in McAllen is engineered – to a degree not typical of many other communities – to encourage doctors to order marginally-necessary, or even unnecessary, tests, and to prescribe costly treatments that may be no more effective than cheaper alternatives.

There are lots of reasons for this. According to Gawande, it’s a complex constellation of factors, including:

- a high rate of for-profit, physician-owned medical facilities;
- an entrepreneurial culture that sees doctors as businessmen and -women, rather than healers;
- a well-founded fear of lawsuits that leads to defensive medicine;
- comparatively less coordination of care than in other places, leading to duplication of services.

“Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.”

It’s the system’s fault, says Gawande. This is a classic example of a systemic problem.

Gawande compares McAllen to another town that’s in the lowest 15 percent of health care costs, nationwide: Rochester, Minnesota, home of the world-famous Mayo Clinic. The most significant difference is that a high percentage of doctors in Rochester are employees of the clinic, rather than entrepreneurial owners of their own little medical businesses. Success in that setting is measured in healthy patients, not the number of patients served. The medical system in Rochester is engineered to maximize health outcomes rather than profits.

They say this article has become required reading in the White House, by staffers tasked with proposing to Congress a workable fix for the health-care funding crisis.

No wonder.

The American solution to medical cost-containment, until now, has been to rely on the insurance companies to ride herd on all this Wild West confusion. The only problem is, the insurance companies are no more concerned with positive health outcomes than physicians are. The insurance companies work for their stockholders, not for the patients.

We need to develop a health-care system that does work for the patients. Other countries (Britain, Canada, France) seem to know how do this better than we. This is a rare opportunity for our national leaders to think outside the box and develop a funding system that truly serves the greatest number of people.

Just don’t blow it, politicians. Take the lobbyists’ hands out of your pockets and pay attention to your constituents. We’re hurtin’ out here – especially in places like McAllen, Texas.

July 15, 2009 - A Common Story

Last night, Claire and I, along with our daughter Ania and niece Elizabeth, went to a midnight premiere of the film, Harry Potter and the Half-Blood Prince. It did not disappoint.

We’ve been fans of the Harry Potter books for some time, and have eagerly awaited each film as it’s come out.

I was struck by how many people showed up at our local multiplex (they were showing the film on at least two of their screens, possibly more). It’s a remarkable thing how many people of all ages have come to know and love these stories: enough to fill cinemas across the country till half-past three in the morning – and on a workday, at that. Judging from the comments we overheard, a great many of our fellow Potter-o-philes are very familiar indeed with minute details of J.K. Rowling’s teenage-wizarding yarn.

It’s a great thing to have a common story.

I was led to wonder how many people, in these days of secularism, feel such a passionate connection with the biblical story? Once upon a time, novelists, playwrights, screenwriters and other creative types could assume their audience could easily recognize biblical allusions. For example, I’ve been listening to a recording of Steinbeck’s great novel, East of Eden, as I drive around in the car. The book’s loaded with biblical symbolism. Were Steinbeck writing today, would he bother to tie his story so closely to archetypal biblical tales like that of Cain and Abel? Would his readers care?

The success of the Harry Potter oeuvre – and Tolkien’s Lord of the Rings before it – speaks to this secular culture’s hunger for a common story, a deeply moral tale grounded in religious sensibilities.

Every time I attend my monthly Leukemia and Lymphoma Society support group (and it’s been several months now since I’ve been there, due to schedule conflicts), I’m impressed by the power of the common story we cancer survivors share. The details, diagnoses and treatments may differ, but there’s a deep well of common experience. In a very real way, the story of my fellow group members is my story too.

Yes, it is a great thing to have a common story.

July 6, 2009 - A Week in Rivendell

Claire and I are spending the week at the Presbyterian House in Chautauqua, New York. Part of the venerable Chautauqua Institution, the Presbyterian House is an old-fashioned guesthouse that accommodates about 65 people. It’s adjacent to the 5,000-seat open-air Auditorium that’s the site of the principal concert, lecture and worship events that take place here.

I’m serving as Chaplain at the Presbyterian House. My duties are pretty light: I preached a sermon on Sunday, offer grace at meals and will conduct a program of my choice on Thursday evening (I’ll lead a discussion on John Calvin, since his 500th birthday is the next day). For this, Claire and I get free room and board for a week, as well as a “gate pass” that gets us into most of the concerts and events that take place here. A generous offer on the part of the Presbyterian House board, for which we’re very grateful.

Chautauqua’s quite an experience: a throwback, in many ways, to the early years of the 20th Century. It’s a picturesque lakeside village filled with Victorian-gingerbread houses. Cars are pretty much banned 7 days a week; the whole place is surrounded by a fence, and – except for Sundays – you have to have a gate pass (admission ticket) to get in. Some people own homes here, and others either rent places or stay in the many hotels and guest houses. Lots of people we’ve met have been coming here for decades.

Sitting in the Auditorium on Sunday, listening to Samuel Wells, chaplain of Duke University (the preacher for the week) give an excellent sermon, I was struck by how insular Chautauqua is. Introducing Sam was Joan Brown Campbell, former director of the National Council of Churches, who’s now head of the Department of Religion here.

Chautauqua is a bastion of old-time, liberal mainline Protestantism. While most historians agree the Protestant Ascendancy in America reached its high-water mark decades ago, in the Eisenhower era, you’d never know it here in this place. Looking out at the nearly-full auditorium, listening to the spirited singing of classic hymns accompanied by a massive pipe organ, I was struck by how much the place feels like a protected island in the storm.

Out there, mainline Protestant churches are struggling against fearsome cultural tides that threaten to sweep us away. Many local churches are enmeshed in “worship wars” that pit fans of guitar-accompanied praise songs against those who love organ-accompanied hymns. We’re beset by interminable, destructive debates over sexual ethics. My own baby boomer generation seems to be the first generation of Christians ever that doesn’t understand what committed, regular financial stewardship is all about, so many churches are cutting budgets and downsizing (and were doing so even before the present recession began). Out there, these are tough days to try to pastor a mainline Protestant church.

In here, though – inside the Chautauqua bubble – it’s as though none of this were happening. Life goes on here, as it has for generations. The faces of the preachers, lecturers and musicians change, of course, but the overall program is much as it’s always been.

Bill, a friend of mine, describes it as "Disneyland for intellectuals."

A literary metaphor occurred to me, as I was sitting there that first day, that to me describes the role Chautauqua plays in the mainline church. This place is Rivendell.

In J.R.R. Tolkien’s The Hobbit and The Lord of the Rings trilogy, Rivendell is the sheltered community of elves, whose powerful magic keeps creeping evil at bay. Much of Middle Earth is quaking in fear at the advancing armies of Saruman, and his more-powerful ally, the Dark Lord of Mordor, but in Rivendell, all is peaceful. When Frodo Baggins and his band of travelers reach Rivendell after facing all manner of perils, they know they are safe for as long as they tarry within the elves’ circle of protection.

Eventually, even the elves themselves will depart their “last homely house,” and somberly sail off in their elegantly-crafted sailboats to eternal life in the Grey Havens – which seems to function, in the Tolkien novels, as something like heaven. But, for the present, Rivendell is a haven in the storm, a place of rest, refreshment, and re-equipping for the battle.

I can use this sort of R&R in a personal sense, of course. I haven’t been thinking about cancer much, while I’m here – although a few Presbyterian House residents, knowing of my history with lymphoma, have come up to me to share their own struggles with the disease. I’ve been thinking a good deal more about how wonderful life in the mainline Protestant church would be if all our congregations were filled with members and ministers like the good folks here. There’s a real spirit of caring and openness and generosity that permeates the place. Would that we could recreate it in our own communities back home!

Looking out over the auditorium congregation, I was also struck by how much gray and white hair there is. This place is teeming with AARP members. Many of the younger folks we’ve met – twenty- and thirty-somethings with kids in tow – are here with their parents and grandparents. It’s a popular spot for family reunions. Would the younger ones choose to come on their own?

All of which raises the question.... Whither mainline Protestantism? Will this congenial crowd return to their home churches, refreshed and renewed, equipped to bear witness to the gospel in edgy, new ways? Or, will they hang around spiritual oases like this a while longer, before packing it in and sailing off to the Grey Havens one day?

I’ve got a feeling the renewal of the mainline church won’t be sparked in places like Chautauqua. As wonderful as this place feels, it’s more about the past than the future.

But even so, it feels good to rest here a little while. Even the Fellowship of the Ring had to take a breather in Rivendell.

July 3, 2009 - Profits and Pain

A recent editorial in one of my favorite journals, The Christian Century, raises a pertinent question about the present healthcare-reform debate:

“The logic of putting citizens into a government-sponsored insurance pool is clear: it drastically cuts overhead, equalizes care, and meets the needs of those who can't afford or obtain coverage from for-profit insurers, who cut their costs by excluding patients with serious medical problems – precisely the people who most need the insurance and the medical care. But that logic alone will hardly slay the hardline defenders of the for-profit insurance system. The political and practical question of the moment... is whether there is any viable compromise – is there a coherent incremental step between the private system we have now and a full-fledged single-payer public plan?”

President Obama seems to think there is – which is why he’s backed away from his campaign promise to move expeditiously to a single-payer health system. Now, he’s mired in the boggy no-man’s-land between the single-payer advocates on the one hand and the insurance companies (clinging to the tattered remnants of our dysfunctional healthcare-funding system) on the other. He’s dodging rotten tomatoes being hurled from both sides.

It’s a battle of ideologies: between the free-market true-believers on the one hand – who are convinced not only that “the business of America is business,” as Calvin Coolidge famously said, but that the best marketplace regulation is no regulation – and those who believe history teaches, on the other hand, that a capitalist economy will end up eating its young if government doesn’t step in with some timely regulation.

In the same issue of The Christian Century, social ethicist Gary Dorrien makes this important observation:

“A fair amount of time has to be spent repeating over and over that single-payer is not socialized medicine, and a public option among private competitors is even farther from it. But we are approaching the point where opponents of health-care reform will start to stress the opposite concern. Their concern is not that a government program won’t work. The real worry, for all who want to keep the present system, is that a government program will work too well.”

“Working too well,” of course, means cutting into Big Insurance’s profits.

Are profits always good? That’s the essential question. Are they still good, even when the unfettered pursuit of profits causes pain for increasing numbers of people? How many of our neighbors must feel pain before the larger culture sits up and takes notice, demanding substantive change? How many uninsured and undertreated Americans is our system willing to throw under a speeding ambulance, before we’re willing to even consider following the lead of just about every other industrialized nation, implementing a national health-insurance system?

That’s the question I sigh and ask myself these days, anyway, as I scan the headlines.